Inspection Reports for Highland Park Care Center

1633 Sweetwater, ALLIANCE, NE, 69301

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Deficiencies (last 12 years)

Deficiencies (over 12 years) 7.5 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

79% worse than Nebraska average
Nebraska average: 4.2 deficiencies/year

Deficiencies per year

16 12 8 4 0
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2022
2025

Census

Latest occupancy rate 88% occupied

Based on a August 2018 inspection.

Census over time

35 42 49 56 63 70 Apr 2011 May 2013 Jun 2015 Jul 2017 Aug 2018
Inspection Report Renewal Capacity: 60 Deficiencies: 0 Mar 10, 2025
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related renewal certifications for Highland Park Care Center, indicating the facility's license renewal process and compliance with state regulations.
Findings
The documents confirm that Highland Park Care Center meets statutory requirements for licensure renewal as a Skilled Nursing Facility with special care units including Alzheimer's/Special Care, Physical Therapy, Speech Therapy, and Occupational Therapy. The renewal application includes facility details, ownership, accreditation, and special care endorsements.
Report Facts
Number of beds to be relicensed: 60 Maximum capacity for Alzheimer's beds: 16 Renewal license fee: 1750
Employees Mentioned
NameTitleContext
Alice SmithAdministratorNamed in Nursing Home Licensure Renewal Application and Alzheimer's Special Care Unit Disclosure
Hannah BaileyDirector of NursingNamed in Nursing Home Licensure Renewal Application
Brian StuhrAuthorized RepresentativeSigned Nursing Home Licensure Renewal Application and Alzheimer's Special Care Unit Disclosure
Glenn Van EkerenAuthorized RepresentativeSigned Nursing Home Licensure Renewal Application
Inspection Report Renewal Capacity: 60 Deficiencies: 0 Feb 16, 2022
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related certification and occupancy permit for Highland Park Care Center, indicating the facility's license renewal process and compliance with statutory requirements.
Findings
The documents confirm that Highland Park Care Center meets statutory requirements for licensure renewal as a Skilled Nursing Facility with special care designations including Alzheimer's/Special Care Unit and various therapies. The facility holds a valid occupancy permit for 60 beds.
Report Facts
Number of beds to be relicensed: 60 Maximum Occupancy: 60 Maximum Capacity for Alzheimer's Beds: 16 Renewal License Fees: 1550
Employees Mentioned
NameTitleContext
Alice SmithAdministratorNamed as facility administrator in licensure and Alzheimer's care applications
Sue RiceDirector of NursingNamed as Director of Nursing in Nursing Home Licensure Renewal Application
Brian StuhrAuthorized RepresentativeSigned renewal application and Alzheimer's care application as contact and authorized representative
Glenn Van EkerenAuthorized RepresentativeSigned renewal application as authorized representative
Document Capacity: 60 Deficiencies: 0 Mar 16, 2020
Visit Reason
The document serves as a renewal application for the nursing home license of Highland Park Care Center, including certification of licensure, occupancy permit, and Alzheimer's Special Care Unit disclosure.
Findings
The documents verify licensure renewal through March 31, 2021, confirm the facility's licensed capacity as 60 beds, and provide detailed information about the Alzheimer's Special Care Unit philosophy, staffing, safety, life enrichment, family support, and fees.
Report Facts
Licensed capacity: 60 Alzheimer's Special Care Unit capacity: 16 Renewal license expiration date: License expires on 2021-03-31 as per certification. Cost/Fees of care: 200
Employees Mentioned
NameTitleContext
Alice SmithAdministratorNamed as facility administrator in the renewal application and Alzheimer's Special Care Unit disclosure.
Sue RiceDirector of NursingNamed as Director of Nursing in the renewal application.
Jack D. VetterAuthorized RepresentativeSigned the renewal application and Alzheimer's Special Care Unit disclosure as authorized representative.
Julie KnobbeContact for Alzheimer's Special Care UnitNamed as contact person for the Alzheimer's Special Care Unit disclosure.
Pat GouldDeputy State Fire MarshalInspected the facility for the occupancy permit.
Inspection Report Complaint Investigation Deficiencies: 0 Feb 6, 2020
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to ensure the documented indication for the use of antibiotic, dosage, and duration is appropriate.
Findings
The facility was found to be in compliance with regulatory requirements, ensuring appropriate documentation for antibiotic use, dosage, and duration based on review of practitioner orders, laboratory results, and interviews with staff.
Complaint Details
The complaint alleged that the facility failed to ensure the documented indication for the use of antibiotic, dosage, and duration was appropriate. The complaint was not substantiated as the facility was found compliant.
Employees Mentioned
NameTitleContext
Connie VogtProgram ManagerSigned the report and identified as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health
Inspection Report Complaint Investigation Deficiencies: 0 May 14, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to use appropriate interventions to prevent injuries.
Findings
The facility used appropriate interventions to prevent injuries related to falls. Staff and residents were interviewed, observations were conducted, and medical records were reviewed with no concerns revealed. The facility was determined to be in compliance with the related regulatory requirements.
Complaint Details
The complaint alleged that the facility failed to use appropriate interventions to prevent injuries. The complaint was investigated and found to be unsubstantiated as the facility was in compliance.
Employees Mentioned
NameTitleContext
Connie VogtProgram ManagerNamed as the Program Manager of the Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS, sender of the report.
Notice Deficiencies: 0 Sep 5, 2018
Visit Reason
The facility's license was placed on probation for 90 days starting September 20, 2018, due to violations related to failure to ensure interventions to prevent falls with injuries. The notice outlines the terms and conditions of probation and required corrective actions.
Findings
The facility was found in violation of multiple licensure regulations related to resident rights, assessments, care plans, accident prevention, and sanitary conditions. The violations were evidenced by failure to implement interventions to prevent falls with injuries.
Report Facts
Probation period: 90 Report submission frequency: 14 Notice finalization date: Sep 20, 2018
Employees Mentioned
NameTitleContext
Connie VogtRN BSN, Program ManagerContact person for submission of reports and correspondence related to probation
Courtney N. PhillipsPhD, Chief Executive OfficerSigned the Notice of Disciplinary Action
Becky WisellAdministrator, Licensure UnitMentioned in relation to the Notice of Disciplinary Action
Linda StenversStaff Assistant IICertified service of the Notice of Disciplinary Action
Alice SmithAdministratorFacility administrator addressed in the termination letter of probation
Inspection Report Routine Census: 53 Capacity: 60 Deficiencies: 16 Aug 23, 2018
Visit Reason
Routine state survey inspection of Highland Park Care Center to assess compliance with health and safety regulations including resident care, safety, and facility conditions.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of transfers, incomplete significant change assessments, inaccurate MDS assessments, incomplete care plans, inadequate care for skin abrasions and bruises, fall prevention interventions, urinary continence assessments, nurse aide annual performance evaluations, behavioral health documentation, pharmacy narcotic count procedures, psychotropic drug monitoring, food service sanitation and dietary preference accommodations, fire sprinkler maintenance, combustible storage control, oxygen use safety, and infection control practices related to CPAP equipment.
Severity Breakdown
SS=D: 11 SS=E: 3 SS=F: 2 SS=G: 1
Deficiencies (16)
DescriptionSeverity
Failed to notify resident or representative in writing of hospital transfers for Resident 54.SS=D
Failed to complete significant change MDS assessment or document rationale for Resident 10's condition changes.SS=D
Failed to accurately record significant weight loss on MDS for Resident 10.SS=D
Failed to develop care plan with goals and interventions for Resident 12's seasonal allergies.SS=D
Failed to assess and provide care for abrasions and bruising for Residents 39 and 46.SS=D
Failed to ensure interventions to prevent recurrent falls with injuries for Resident 54.SS=G
Failed to assess decline in urinary continence and follow up on UTI symptoms for Resident 50.SS=D
Failed to complete annual performance evaluation for one nursing assistant.SS=E
Failed to follow pharmacist recommendation to monitor behavior when administering Viibryd for Resident 18.SS=D
Failed to consistently provide preferred gluten free food for Resident 44.SS=D
Failed to date and label open food packages, repair cracked ceiling, clean ceiling vents, and use proper hand hygiene during meal service.SS=F
Failed to maintain fire sprinkler system free of grease and lint buildup in kitchen and laundry areas.SS=F
Failed to control combustible materials in storage room on resident wing 200.SS=E
Failed to ensure oxygen concentrators were turned off when not in use in resident rooms.SS=E
Failed to maintain confidentiality and completeness of resident behavior monitoring records for Residents 1 and 12.SS=D
Failed to ensure CPAP equipment was cleaned and stored properly and distilled water containers were dated for Resident 21.SS=D
Report Facts
Facility census: 53 Total licensed capacity: 60 Number of sampled residents: 22 Number of nursing assistants personnel files reviewed: 5 Number of residents affected by narcotic count issue: 5 Number of residents in Special Care Unit: 16 Number of residents in resident wing 200: 20 Number of residents in resident wing 300: 22
Employees Mentioned
NameTitleContext
Alice SmithAdministratorNamed in multiple findings and correspondence
Dee Dee BehmLPNParticipant in informal conference
Kimberly A. DivisRN, NSSCReviewer of informal conference
LPN-CLicensed Practical NurseNamed in narcotic count findings
LPN-ERegistered Nurse, MDS CoordinatorNamed in MDS assessment findings
LPN-GLicensed Practical NurseNamed in care plan and behavior monitoring findings
Dietary ManagerNamed in food preference and sanitation findings
DC-FDietary CookNamed in food handling findings
LA-DLaundry AideNamed in unmarked clothing findings
LPN-ALicensed Practical NurseNamed in infection control findings
Administrator ANamed in fire sprinkler and combustible storage findings
Maintenance ANamed in fire sprinkler and combustible storage findings
Inspection Report Complaint Investigation Deficiencies: 0 Jun 6, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to investigate causative factors in falls.
Findings
The investigation included observations of three residents with recent falls, staff interviews, and record reviews. Fall interventions were found to be in place, and causal factors were appropriately investigated. The facility was found to be in compliance with related regulatory requirements.
Complaint Details
The complaint alleged that the facility fails to investigate for causative factors in falls. The allegation was investigated and found to be unsubstantiated as the facility was in compliance.
Report Facts
Residents observed for falls: 3
Employees Mentioned
NameTitleContext
Dan TaylorRN, Training CoordinatorSigned the report and identified as representative of the Office of LTC Facilities - Licensure Unit
Inspection Report Renewal Census: 60 Capacity: 60 Deficiencies: 0 Feb 28, 2018
Visit Reason
The document is a renewal application and certification for Highland Park Care Center's SNF/NF dual certification license renewal.
Findings
The facility is licensed for 60 beds and provides specialized care including Alzheimer's/Special Care Unit, Physical Therapy, and Speech Therapy. The renewal application includes detailed information about ownership, staffing patterns, and care philosophy.
Report Facts
Number of beds to be relicensed: 60 Maximum occupancy: 60 Maximum endorsed capacity: 16 Staffing numbers: 1 Staffing numbers: 3 Staffing numbers: 1 Staffing numbers: 2 Staffing numbers: 1 Staffing numbers: 1 Staffing numbers: 1 Base cost/fee of care: 181
Employees Mentioned
NameTitleContext
Robin PowellAdministratorNamed in facility information and renewal application
Lisa MullenDirector of NursingNamed in facility information
Jack D. VetterCEOAuthorized representative signing renewal application
Glenn Van EkerenPresidentNamed as officer of ownership entity
Julie KnobbeContact name for legal owning entity
Inspection Report Complaint Investigation Census: 46 Capacity: 47 Deficiencies: 11 Jul 6, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Highland Park Care Center on July 6, 2017-July 12, 2017, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to be in compliance with allegations of insufficient staffing, delayed response to calls for assistance, and reporting of falls. However, a citation was issued for failure to provide care and services according to practitioner's orders. Multiple deficiencies were identified including privacy violations during medical procedures, failure to include nurse aides in care plan development, failure to update care plans, failure to follow physician orders, unsafe storage of chemicals, improper diet provision, unsanitary food handling, medication administration errors, medication storage and labeling issues, failure to consult medical director in a medication dispute, and fire safety code violations related to smoke barriers and cubicle curtains.
Complaint Details
The complaint allegations included insufficient staffing, delayed response to calls for assistance, inaccurate and incomplete reporting of falls, and failure to provide care and services according to practitioner's orders. The facility was found compliant with staffing, call response, and fall reporting allegations but cited for failure to provide care according to practitioner's orders.
Severity Breakdown
SS=F: 1 SS=E: 6 SS=D: 3
Deficiencies (11)
DescriptionSeverity
Failed to ensure privacy during medical procedures for one resident.SS=D
Failed to include nurse aides in care plan development and update care plans accordingly.SS=E
Failed to follow physician orders related to a follow-up appointment for one resident.SS=D
Failed to ensure resident environment free from accident hazards; chemicals unsecured on Special Care Unit.SS=E
Failed to ensure resident received diet as ordered by physician.SS=D
Failed to serve food in a sanitary manner; improper hand hygiene and handling by dietary staff.SS=F
Failed to ensure medication labels were compared to orders at least three times before administration and follow-up on medication refusals.SS=E
Failed to ensure prescription labels matched current medication orders and secure medication room access.SS=E
Failed to consult Medical Director for involvement in resolving medication order dispute for one resident.SS=D
Failed to maintain smoke barrier wall free of penetration allowing smoke/fire extension between compartments.SS=E
Failed to provide cubicle curtains with required mesh size to allow sprinkler water coverage.SS=E
Report Facts
Residents interviewed: 13 Families interviewed: 4 Residents observed: 30 Residents sampled for medication administration: 5 Residents sampled for medication review: 5 Residents on Special Care Unit: 13 Medications prepared: 16 Medications prepared: 9 Residents refusing medications: 1 Cubicle curtains non-compliant rooms: 4
Employees Mentioned
NameTitleContext
Robin PowellAdministratorFacility administrator receiving report and involved in exit interviews
Eve LewisProgram Manager - Office of LTC Facilities - Licensure UnitAuthor of complaint investigation letter
LPN ALicensed Practical NurseNamed in privacy violation and medication administration deficiencies
LPN BLicensed Practical NurseNamed in medication administration and medication labeling deficiencies
LPN CLicensed Practical NurseNamed in medication administration and medication room access deficiencies
LPN DLicensed Practical NurseNamed in medication administration and medication refusal follow-up deficiencies
RN JMDS CoordinatorNamed in care plan development deficiencies
Director of NursingDirector of NursingNamed in multiple findings including privacy, medication administration, and medical director consultation
NPNurse PractitionerNamed in medication order dispute
Cook FCookNamed in diet and food handling deficiencies
Cook GCookNamed in diet and food handling deficiencies
Dietary ManagerDietary ManagerNamed in diet and food handling deficiencies
LPN ELicensed Practical Nurse, Infection Control NurseNamed in care plan and medication follow-up deficiencies
LPN BUnit CoordinatorNamed in chemical storage deficiency
Maintenance Personnel 1Maintenance PersonnelNamed in fire safety deficiency
Inspection Report Complaint Investigation Census: 46 Capacity: 47 Deficiencies: 10 Jul 6, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Highland Park Care Center from July 6 to July 12, 2017, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The investigation found the facility in compliance with staffing, call response, and fall reporting allegations. However, a citation was issued for failure to provide care according to practitioner's orders. Additional deficiencies were found related to privacy during medical procedures, care plan participation and updates, medication administration, food service sanitation, medication storage and labeling, medical director responsibilities, and life safety code violations including smoke barrier penetrations and cubicle curtain specifications.
Complaint Details
The complaint allegations included insufficient staffing, delayed response to calls for assistance, inaccurate reporting of falls, and failure to provide care according to practitioner's orders. The facility was found compliant with staffing, call response, and fall reporting but cited for failure to provide care according to practitioner's orders.
Severity Breakdown
SS=D: 4 SS=E: 4 SS=F: 1
Deficiencies (10)
DescriptionSeverity
Failed to ensure privacy during medical procedures for one resident.SS=D
Failed to include nurse aides in care plan development and update care plans to reflect current treatments for several residents.SS=E
Failed to follow physician orders related to follow-up appointment for wound evaluation.SS=D
Failed to ensure resident received diet as ordered by physician.SS=D
Failed to serve food in a sanitary manner, including improper hand hygiene and handling by dietary staff.SS=F
Failed to ensure medication labels were compared to orders three times before administration and failed to follow up on medication refusals.SS=E
Failed to ensure prescription labels matched current medication orders and restricted medication room access to authorized personnel only.SS=E
Failed to consult Medical Director for involvement in resolving dispute regarding antibiotic medication order.SS=D
Failed to maintain smoke barrier wall free of penetration allowing smoke/fire extension between compartments.SS=E
Failed to provide cubicle curtains with required 1/2 inch mesh openings at top to allow sprinkler water coverage.SS=E
Report Facts
Residents sampled for medication administration observations: 5 Residents sampled for medication review: 5 Residents on Special Care Unit at risk: 10 Residents sampled for care plan review: 16 Residents sampled for observations: 30 Residents sampled for medication administration: 5 Residents on mechanical soft diet: 1 Facility census: 46 Facility licensed capacity: 47
Employees Mentioned
NameTitleContext
Robin PowellAdministratorNamed as facility administrator in complaint investigation letter and civil rights compliance form
Eve LewisProgram Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHSSigned complaint investigation letter
LPN ALicensed Practical NurseNamed in medication administration and privacy deficiency findings
LPN BLicensed Practical NurseNamed in medication administration and medication labeling deficiency findings
LPN CLicensed Practical NurseNamed in medication administration and medication room access deficiency findings
LPN DLicensed Practical NurseNamed in medication administration deficiency findings
RN JMDS CoordinatorNamed in care plan development deficiency findings
Director of NursingDirector of NursingNamed in multiple findings including privacy, medication administration, and medical director consultation
Cook FCookNamed in food service sanitation deficiency
Cook GCookNamed in food service sanitation deficiency
NPNurse PractitionerNamed in medical director consultation deficiency
Maintenance Personnel 1Maintenance PersonnelNamed in smoke barrier deficiency
Administrator AAdministratorNamed in smoke barrier and cubicle curtain deficiencies
Inspection Report Renewal Capacity: 60 Deficiencies: 0 Jul 1, 2017
Visit Reason
The document package relates to the renewal and change of ownership of the Skilled Nursing Facility license for Highland Park Care Center, including licensure issuance, facility information updates, and compliance with regulatory requirements.
Findings
The documents confirm that Highland Park Care Center meets statutory requirements for SNF/NF dual certification, with no deficiencies or enforcement actions noted. The facility provides specialized memory support services and complies with state regulations for licensing and operation.
Report Facts
Total licensed beds: 60 Memory Support Household capacity: 16 Daily room rates: 171 Daily room rates: 182 Daily room rates: 186 Memory support daily rate: 10
Employees Mentioned
NameTitleContext
Robin PowellAdministratorNamed as facility administrator in licensure application and correspondence.
Jack D. VetterChairman of the Board and CEONamed as Chairman and CEO of Vetter Senior Living and signatory on ownership documents.
Shari TerryChief Operations OfficerSigned letter submitting change of ownership documents to Nebraska Department of Health and Human Services.
Julie KnobbeContact for VSL Alliance, LLCNamed contact person for ownership entity in Alzheimer's Special Care Unit Disclosure.
Document Deficiencies: 0 Jun 9, 2017
Visit Reason
This document certifies that the policies of insurance listed have been issued to the insured for the policy period indicated.
Findings
The certificate lists coverage limits for commercial general liability, professional liability including sexual misconduct, and employee benefits liability.
Report Facts
Insurance coverage limit: 1000000 Insurance coverage limit: 3000000 Insurance coverage limit: 1000000 Insurance coverage limit: 3000000 Insurance coverage limit: 1000000
Inspection Report Renewal Capacity: 60 Deficiencies: 0 Mar 23, 2017
Visit Reason
The document is a renewal application and certification for the Skilled Nursing Facility license of Highland Park Care Center, verifying licensure through the renewal date and confirming compliance with statutory requirements.
Findings
The documents describe the facility's licensure renewal, certification, occupancy permit, ownership, and detailed programmatic information about the Memory Support Household for residents with Alzheimer's and dementia, including philosophy, admission criteria, staffing, training, environment, care approaches, family support, and safety policies.
Report Facts
Total licensed beds: 60 Maximum endorsed capacity for Memory Support Household: 16 Renewal fees: 1750 Daily room rates: 171 Daily room rates: 182 Daily room rates: 186 Memory support daily rate: 10 Level of care daily rates: 25 Level of care daily rates: 34 Level of care daily rates: 46 Level of care daily rates: 54 Level of care daily rates: 64 Level of care daily rates: 73
Employees Mentioned
NameTitleContext
Robin PowellAdministratorNamed in licensure renewal application
Teresa McFarlandDirector of NursingNamed in licensure renewal application
Jack D. VetterChair of the Board & CEONamed in ownership and certification documents
Julie KnobbeContact for Alliance Health Care, Inc.Named in Alzheimer's Special Care Unit Disclosure
Inspection Report Annual Inspection Census: 50 Capacity: 60 Deficiencies: 13 Aug 3, 2016
Visit Reason
Annual inspection of Highland Park Care Center to assess compliance with state and federal regulations including resident rights, housekeeping, assessments, medication administration, food service, and safety.
Findings
The facility was found deficient in allowing a resident choice in bedtime, housekeeping and maintenance issues including cleanliness and repair of toilets and walls, replacement of worn linens, failure to complete significant change assessments, inaccurate resident weight documentation, oxygen concentrator safety, medication timing errors, food service sanitation, and incomplete clinical record documentation. The facility also lacked a qualified Dietary Manager. Some deficiencies were later dismissed or modified after informal dispute resolution.
Severity Breakdown
SS=D: 7 SS=E: 3 SS=F: 1
Deficiencies (13)
DescriptionSeverity
Failed to allow Resident 33 a choice in bedtime, putting her to bed at 6:00 PM against her preference.SS=D
Failed to ensure cleanliness and good repair of toilets in multiple rooms and painted patched wall in Room 301.SS=E
Failed to replace worn and frayed hand towels in six sampled residents' bathrooms.SS=E
Failed to complete a comprehensive significant change MDS assessment for Resident 51 after notable declines in condition.SS=D
Failed to accurately record resident weight on MDS for Resident 32.SS=D
Oxygen concentrators were left on when not in use, creating a fire hazard for two residents.SS=D
Medication timing errors for Omeprazole administration for two residents, resulting in an 8% medication error rate.SS=D
Food service sanitation issues including unclean utensil drawers, food particles in flour bin, greasy stove burners, improper glove use, dusty spice containers, and serving instant breakfast supplement above required temperature.SS=F
Failed to maintain complete and accurate clinical records for medications and treatments for sampled residents.SS=E
Facility failed to employ a qualified Dietary Manager; acting manager had not completed accredited training.
Electrical fixture in oxygen storage room installed lower than 5 feet above floor, posing fire hazard.SS=D
Towel bars in semi-private rooms labeled with only one resident identifier, creating potential for cross contamination.
Resident call light system in one room was non-functional due to pinched cord but was corrected during observation.
Report Facts
Facility census: 50 Total licensed capacity: 60 Medication error rate: 8 BIMS score: 8 Weight loss percentage: 9.5
Employees Mentioned
NameTitleContext
Robin PowellAdministratorNamed as facility administrator in multiple documents
Dain WeissRN, Peer Review OrganizationConducted Informal Conference/Dispute Resolution
Dan TaylorRN, Training CoordinatorSigned Informal Dispute Resolution report
Alice SmithOffice ManagerParticipant in Informal Conference
Maintenance AConfirmed electrical fixture height deficiency
LPN-ALicensed Practical NurseInterviewed regarding resident bedtime
Nursing Assistant-BInterviewed regarding resident bedtime routine
Life Enrichment CoordinatorInterviewed regarding resident bedtime preference
IDONInterim Director of NursingInterviewed regarding assessments, medication errors, and documentation
Staff Development CoordinatorResponsible for medication pass audits and staff education
AdministratorInterviewed regarding food service sanitation and call light system
Dietary ManagerActing Dietary Manager without full certification
Dietary Aid-DObserved serving food and measuring temperatures
Inspection Report Complaint Investigation Census: 49 Deficiencies: 6 Jun 16, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Highland Park Care Center on June 16-18, 2015. The complaint allegations included insufficient staffing and failure to protect residents from abuse.
Findings
The facility was found to have sufficient staff and did protect residents from abuse with no deficiencies cited for these issues. However, deficiencies were identified in housekeeping and maintenance, medication management, dietary services, pharmaceutical services, infection control, and ventilation.
Complaint Details
The complaint alleged insufficient staffing and failure to protect residents from abuse. Investigations found no concerns or deficiencies related to staffing or abuse.
Severity Breakdown
E: 3 D: 2 F: 1
Deficiencies (6)
DescriptionSeverity
Facility failed to repair wall gouges and marring for two sampled residents and cracked bathroom floor tiles for two sampled residents.E
Facility failed to ensure residents' drug regimen was free from unnecessary drugs, specifically failure to question continued use of three diuretics and monitor electrolytes for one resident, resulting in low potassium and sodium levels.D
Facility failed to employ and designate a qualified Director of Food Service/Dietary Manager.F
Facility failed to prevent administration of a discontinued diuretic medication for one resident.D
Facility failed to ensure resident towel bars were labeled to reduce risk of cross contamination in shared restrooms.E
Facility failed to ensure bathroom exhaust fans were in working order for bathrooms affecting nine sampled residents.E
Report Facts
Facility census: 49 Number of residents sampled for ventilation deficiency: 9 Number of residents sharing unlabeled towel bars: 14 Number of diuretics used: 3 Number of doses of discontinued medication administered: 5
Employees Mentioned
NameTitleContext
Robin PowellAdministratorInterviewed regarding wall repairs and towel bar labeling
Kathy GibbonsSocial WorkerSurveyor involved in complaint and annual survey investigation
Keeli KleinRegistered NurseSurveyor involved in complaint and annual survey investigation
Joseph SchumacherRegistered NurseSurveyor involved in complaint and annual survey investigation
Kaylene StraetkerRegistered NurseSurveyor involved in complaint and annual survey investigation
Eve LewisProgram ManagerSigned letter communicating survey results
LPN-BLicensed Practical Nurse, Unit CoordinatorInterviewed regarding medication monitoring and towel bar labeling
LPN-CLicensed Practical NurseInterviewed regarding towel bar labeling
Cook-ACookInterviewed regarding dietary manager position
Inspection Report Complaint Investigation Census: 54 Deficiencies: 3 Mar 25, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Highland Park Care Center on March 25-27, 2014. The complaint allegations included failure to provide staffing according to regulations, failure to ensure sufficient staffing to care for residents, and failure to ensure residents are free from abuse.
Findings
Following investigation, the facility was found to meet resident needs regarding staffing and resident satisfaction with no violations. The facility was also found to be protecting residents from abuse and following policies and regulatory requirements. However, deficiencies were identified related to care planning and monitoring of an antibiotic eye ointment for one resident, and food storage and temperature monitoring practices in the kitchen.
Complaint Details
The complaint allegations were related to staffing adequacy and resident abuse. The investigation included interviews with residents, families, staff, and administrative personnel; observations of resident care; and review of records and policies. No violations were found regarding staffing or abuse.
Severity Breakdown
SS=D: 2 SS=F: 1
Deficiencies (3)
DescriptionSeverity
Facility failed to address the routine use of an antibiotic eye ointment on the care plan for one resident (Resident 34).SS=D
Facility failed to obtain a diagnosis and monitor the routine use of an antibiotic eye ointment for one resident (Resident 34).SS=D
Facility failed to ensure that two boxes of ice cream were not stored on the floor in the freezer to reduce risk of cross contamination and failed to monitor and document refrigerator and freezer temperatures daily.SS=F
Report Facts
Facility census: 54 Dates missing refrigerator temperature documentation: 6 Dates missing freezer temperature documentation: 6
Employees Mentioned
NameTitleContext
Robin PowellAdministratorNamed in initial comments and signature on deficiency statements
Dan TaylorRN, Training CoordinatorSigned complaint investigation letter
Keeli KleinRegistered NurseSurveyor conducting complaint investigation
Gaylynn HolthusRegistered NurseSurveyor conducting complaint investigation
Joseph SchumacherRegistered NurseSurveyor conducting complaint investigation
Kaylene StraetkerRegistered NurseSurveyor conducting complaint investigation
Dietary ManagerInterviewed regarding food storage and temperature monitoring deficiencies
Director of NursingInterviewed regarding care plan and medication monitoring deficiencies
Inspection Report Annual Inspection Census: 52 Deficiencies: 11 May 16, 2013
Visit Reason
The inspection was the annual survey of Highland Park Care Center to assess compliance with state and federal regulations governing skilled nursing facilities.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident privacy during insulin administration, incomplete assessment for self-administration of medications, lack of resident input on bathing schedules, inadequate housekeeping and maintenance of equipment, unsafe resident environment due to unassessed grab bars and worn wheelchair parts, unsanitary food handling practices, medication administration errors, incomplete pharmacist medication regimen reviews, improper labeling of insulin, infection control issues related to ice handling and storage of distilled water, and unsanitary conditions in the activity room refrigerator.
Severity Breakdown
SS=D: 7 SS=E: 4 SS=F: 1
Deficiencies (11)
DescriptionSeverity
Failure to ensure privacy during insulin injection administration for Resident 25.SS=D
Failure to assess Resident 27 for safe self-administration of over-the-counter medications kept at bedside.SS=D
Failure to allow resident input on bathing schedules for Residents 63, 59, and 27.SS=D
Failure to clean or replace soiled wheelchair brake coverings and failure to clean and store respiratory nebulizer equipment properly.SS=D
Failure to assess safety of positioning grab bar and failure to replace worn wheelchair armrest.SS=D
Failure to handle food in a sanitary manner and failure to keep kitchen vents and fans clean.SS=F
Failure to compare medication labels with orders at least three times before administration for multiple residents.SS=E
Failure of pharmacist to review medication regimen monthly for Resident 62.SS=D
Insulin prescription label did not include sliding scale orders for Resident 25.SS=D
Failure to prevent cross contamination during ice handling and improper storage of distilled water.SS=E
Failure to maintain activity room refrigerator in a clean and sanitary condition.SS=E
Report Facts
Facility census: 52 Deficiencies cited: 12
Employees Mentioned
NameTitleContext
LPN ALicensed Practical NurseNamed in findings related to privacy during insulin administration and medication label comparison
LPN BLicensed Practical NurseNamed in findings related to medication label comparison
LPN CLicensed Practical NurseNamed in interview regarding medication regimen review
LPN DLicensed Practical NurseNamed in findings related to bathing schedule and resident mobility
Cook ECookNamed in findings related to unsanitary food handling
NA HNursing AssistantNamed in findings related to ice handling contamination
DONDirector of NursingNamed in multiple interviews confirming deficiencies and policies
Activity DirectorNamed in findings related to unsanitary activity room refrigerator
Inspection Report Routine Census: 53 Deficiencies: 7 May 22, 2012
Visit Reason
Routine state survey inspection of Highland Park Care Center to assess compliance with Nebraska Administrative Code and federal regulations governing skilled nursing facilities.
Findings
The facility was found deficient in several areas including failure to maintain survey results book for resident review, failure to report and assess bruises, delayed response to call lights, failure to activate fall prevention alarms, failure to obtain resident's pulse before administering Digoxin, and ineffective pest control with bugs in resident room lighting. The facility was in compliance with the Life Safety Code.
Severity Breakdown
SS=E: 3 SS=D: 3 SS=G: 1
Deficiencies (7)
DescriptionSeverity
Failed to maintain survey results book for resident review.SS=E
Failed to ensure bath aide reported bruises to licensed nurses for assessment and care.SS=D
Failed to ensure call lights were answered timely to meet resident needs.SS=D
Failed to activate alarm interventions as specified in resident's fall prevention care plan.SS=G
Failed to obtain resident's heart rate prior to administering Digoxin as ordered.SS=D
Failed to maintain effective pest control program; bugs found in bathroom light fixtures in resident rooms.SS=E
Medication aide with expired registration passed medications.
Report Facts
Facility census: 53 Stage 2 sample size: 16 Medication Aide registration expiration date: Dec 1, 2011 Medication Aide re-issue date: Jan 20, 2012 Fall risk score: 21 Bruise size: 4 Bruise size: 3.4 Pulse: 62
Employees Mentioned
NameTitleContext
Alice SmithAdministratorInterviewed regarding survey results book and medication aide registration
Deborah ShinnDirector of NursingInterviewed regarding bruises, call light response, fall prevention, and medication administration
LPN ALicensed Practical Nurse, Unit CoordinatorInterviewed regarding bruises and fall prevention
LPN BLicensed Practical Nurse, Charge NurseObserved administering medication including Digoxin
LPN CLicensed Practical NurseNotified about call light needs
Employee EResponsible for tracking Medication Aide registration expirations
Notice Deficiencies: 0 Apr 25, 2011
Visit Reason
The notice was issued to inform the facility of disciplinary action placing the license on probation for 90 days beginning May 10, 2011, due to failure to implement interventions to prevent pressure sores.
Findings
The Department determined the facility violated licensure regulations related to preventing pressure sores, requiring submission of a Plan of Correction and weekly reports during the probation period.
Report Facts
Probation period length: 90 Probation start date: May 10, 2011 Report due date: May 20, 2011 Notice finalization date: May 10, 2011 Notice mailing date: Apr 25, 2011
Employees Mentioned
NameTitleContext
Joann SchaeferChief Medical Officer, Director, Division of Public HealthSigned the Notice of Disciplinary Action
Helen L. MeeksAdministrator, Licensure UnitSigned the Notice of Disciplinary Action
Linda StenversStaff Assistant IICertified mailing of the Notice of Disciplinary Action
Eve LewisRNC, Administrator, Office of Long Term Care FacilitiesRecipient of reports and author of letter terminating probation
Alice SmithAdministratorFacility administrator addressed in the letter terminating probation
Inspection Report Annual Inspection Census: 45 Capacity: 60 Deficiencies: 13 Apr 11, 2011
Visit Reason
Annual inspection survey conducted to assess compliance with state and federal regulations for skilled nursing facilities.
Findings
The facility was found deficient in multiple areas including resident dignity during meal assistance, care plan development and updates, medication administration, pressure ulcer care, range of motion maintenance, fall prevention, medication error prevention, food service sanitation, pharmaceutical services, clinical record documentation, staff health screenings, dietary manager qualifications, medication administration practices, and life safety code compliance related to corridor obstructions and exit visibility.
Severity Breakdown
SS=E: 1 SS=D: 6 SS=G: 1 SS=F: 3
Deficiencies (13)
DescriptionSeverity
Failed to promote dignity while assisting residents to eat and administer medications, and failed to evaluate residents sitting alone during meals.SS=E
Failed to develop comprehensive care plans addressing functional limitations in range of motion for a sampled resident.SS=D
Failed to update care plans following a fall with injury and routine hypnotic use for sampled residents.SS=D
Failed to provide care to manage left ankle pain and assess heart rate prior to administration of Lanoxin for sampled residents.SS=D
Failed to provide treatment and pressure relief to prevent and heal pressure sores for a sampled resident.SS=G
Failed to provide an exercise program to maintain or prevent decline in range of motion for a sampled resident.SS=D
Failed to provide care interventions to prevent a fall with injury for a sampled resident.SS=D
Failed to administer medications before meals as specified by the manufacturer for two sampled residents.SS=D
Failed to follow handwashing procedures when preparing and serving food, risking contamination.SS=F
Failed to provide routinely scheduled eye medication due to unavailability for a sampled resident.SS=D
Failed to follow standards of practice for medication administration including observing residents swallow medications for three sampled residents.SS=D
Failed to maintain aisles and corridors free of obstructions, specifically patient lift carts stored in corridors.SS=F
Failed to maintain exits and egress free of obstructions, including exit door concealed by decoration.SS=F
Report Facts
Facility licensed capacity: 60 Current census: 45 Sample size: 27 Number of patient lift carts observed: 4 Fall risk assessment score: 8 Pressure ulcer size: 5 Pressure ulcer size: 9 Pressure ulcer size: 12
Employees Mentioned
NameTitleContext
NA-CNurse AideWorked with residents without completed health history screening
NA-DNurse AideWorked with residents without completed health history screening
LPN-BLicensed Practical NurseObserved administering medications improperly and not observing swallowing
RN-BRegistered NurseObserved removing medication when resident refused and not observing swallowing
Cook-MCookFailed to wash hands after picking up food from floor
Cook-NCookWashed hands but turned faucet off with clean hands
Dietary ManagerDietary ManagerDid not meet qualifications at time of survey, enrolled in course
Maintenance AMaintenance StaffConfirmed corridor obstructions and exit door obstruction
LPN-KLicensed Practical NurseResponsible for fall risk assessment with incorrect scoring
DONDirector of NursingConfirmed multiple deficiencies and provided interviews
Notice Capacity: 60 Deficiencies: 0 APP2023
Visit Reason
The document serves as a renewal application for the nursing home license of Highland Park Care Center and includes related certification and licensing information.
Findings
The documents confirm the facility's licensure renewal status, certification for Alzheimer's/Special Care Unit, and occupancy permit with a maximum capacity of 60 beds. It also includes detailed information about the facility's memory support household philosophy and staffing.
Report Facts
Total licensed beds: 60 Maximum Capacity for Alzheimer's Beds: 16 Renewal Licensure Fee: 1550 Renewal Licensure Fee: 1750 Renewal Licensure Fee: 1950
Employees Mentioned
NameTitleContext
Alice SmithAdministratorNamed as facility administrator on renewal application
Sue RiceDirector of NursingNamed as Director of Nursing on renewal application
Brian StuhrContact Name / Authorized RepresentativeListed as contact and authorized representative on Alzheimer's Special Care Unit Disclosure and renewal application
Notice Capacity: 60 Deficiencies: 0 APP2024
Visit Reason
The document package serves to verify the renewal of the SNF/NF Dual Certification license for Highland Park Care Center and includes the renewal application, occupancy permit, and Alzheimer's Special Care Unit disclosure.
Findings
No inspection findings or deficiencies are reported; the documents confirm licensing status, facility capacity, and program details for the Alzheimer's Special Care Unit.
Report Facts
Total licensed beds: 60 Maximum capacity for Alzheimer's beds: 16 Renewal license expiration date: Expires 2025-03-31 as shown on the renewal card.
Employees Mentioned
NameTitleContext
Alice SmithAdministratorNamed as facility administrator on the renewal application.
Hannah BaileyDirector of NursingNamed as Director of Nursing on the renewal application.
Brian StuhrAuthorized RepresentativeSigned renewal application and Alzheimer's Special Care Unit Disclosure.
Glenn Van EkerenAuthorized RepresentativeSigned renewal application.
Notice Capacity: 60 Deficiencies: 0 APP2016
Visit Reason
This document serves as a licensure renewal application and verification for Highland Park Care Center's Skilled Nursing Facility/Nursing Facility dual certification, including occupancy permit and business ownership information.
Findings
The documents confirm the facility's licensure renewal status, maximum occupancy of 60 beds, and provide detailed information about facility ownership, services, and policies related to memory support care.
Report Facts
Total licensed beds: 60 Renewal fees: 1550
Employees Mentioned
NameTitleContext
Robin PowellAdministratorNamed on the Nursing Home Licensure Renewal Application.
Barbara SaumDirector of NursingNamed on the Nursing Home Licensure Renewal Application.
Document Capacity: 60 Deficiencies: 0 APP2019
Visit Reason
The document serves as a renewal application for the facility's license and includes certification of licensure, ownership and corporate officer information, occupancy permit details, and descriptions of the facility's memory support household philosophy and staffing.
Findings
The documents confirm that Highland Park Care Center is licensed as a skilled nursing facility with a maximum occupancy of 60 beds. It includes detailed information on ownership, staffing patterns for memory support, and the facility's approach to dementia care and life enrichment programs.
Report Facts
Maximum Occupancy: 60 Maximum endorsed capacity: 16 Base fee: 188 Date issued: Aug 23, 2018
Employees Mentioned
NameTitleContext
Alice SmithAdministratorNamed as the facility administrator on the renewal application.
Jack D. VetterCEONamed as CEO and authorized representative signing the renewal application.
Sue RiceDirector of NursingNamed as Director of Nursing on the renewal application.
Glenn Van EkerenPresidentNamed as President and authorized representative of Vetter Senior Living related corporations.
Eldora D. VetterSecretaryNamed as Secretary of Vetter Senior Living related corporations.
Brian StuhrTreasurerNamed as Treasurer of Vetter Senior Living related corporations.
Document Capacity: 60 Deficiencies: 0 APP2021
Visit Reason
The document serves as a licensure renewal application for Highland Park Care Center, including certification of licensure, occupancy permit, and Alzheimer's Special Care Unit disclosure.
Findings
The documents verify the facility's licensure status, ownership information, bed capacity, and special care unit endorsement. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 60 Maximum capacity for Alzheimer's beds: 16 Occupancy permit date: Jan 14, 2021
Employees Mentioned
NameTitleContext
Alice SmithAdministratorNamed as administrator on the Nursing Home Licensure Renewal Application and Alzheimer's Special Care Unit Disclosure.
Sue RiceDirector of NursingNamed as Director of Nursing on the Nursing Home Licensure Renewal Application.
Jack D. VetterAuthorized RepresentativeSigned the Nursing Home Licensure Renewal Application and Alzheimer's Special Care Unit Disclosure.
Glenn Van EkerenAuthorized RepresentativeSigned the Nursing Home Licensure Renewal Application.

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